Healthcare Provider Details

I. General information

NPI: 1700815990
Provider Name (Legal Business Name): PAMELA N/A O'FRIEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA N/A GOLD RD

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W JANSS RD SUITE 110
THOUSAND OAKS CA
91360-1848
US

IV. Provider business mailing address

PO BOX 940838
SIMI VALLEY CA
93094-0838
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-6051
  • Fax: 805-496-6785
Mailing address:
  • Phone: 805-433-7777
  • Fax: 805-433-7607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number805535
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: